Physician advisors can help case managers do their job better
Rely on them to intervene when problems arise
If you aren’t taking advantage of the assistance your case management physician advisor can offer, or if you don’t have an advisor, you may be missing opportunities to move patients safely and efficiently through the continuum of care.
Case management directors who work closely with their physician advisor find that the help is invaluable in helping the attending physicians understand coding, admission criteria, and the importance of getting tests and consultations completed and the patient ready for discharge in a timely manner.
"Our physician advisor is always available to me and the case managers at all hours. If they foresee a problem with a denial or length-of-stay issue, they can contact him immediately and not wait until the next day. It’s been a tremendous help in cutting down on denials and avoidable days," says Marilyn Butler, RN, MS, CCM, director of case management at Southern Ocean County Hospital in Manahawkin, NJ.
In many hospitals, case managers and their physician advisors work as a team to address issues that may include length of stay, compliance with the Centers for Medicare & Medicaid Services (CMS) Core Measures, following clinical pathways, and educating physicians on the role of case managers.
"There are so many opportunities to educate physicians. They don’t come out of medical school knowing about case management, and the more they know about it, the more likely they are to be on board. I tell them that we want to be part of their efficiency and to work together to improve patient satisfaction and quality outcomes," says David L. Gormsen, DO, FACEP, chief medical officer and physician advisor to case management at Mercy Medical Center in Canton, OH.
Case managers can call on their physician advisors to intervene to assure that patients meet continuing stay or admission criteria.
"As soon as the case managers feel that a patient is not appropriate under Interqual criteria, they get in touch with the resident or the attending physician. They have a right to ask them questions, and if the physicians don’t answer the case manager’s concerns, I get involved," says Minal Shah, MD, physician advisor to case management at Northshore Hospital at Forest Hills, NY.
Physician advisors also can be helpful when it comes to educating the administration about what the case managers do, how much they contribute to the success of the hospital, and in ensuring that the department gets appropriate support. "This means communicating with the top administration. I do that through a quarterly meeting with the executive staff. I always give a synopsis of the initiatives we are working on and what successes we’ve seen," Gormsen says.
Hospital Case Management looked at the different ways case managers work with their physician advisors. Here’s what we found:
At Southern Ocean County Hospital, the case managers and medical director work as a team to reduce denials and avoidable days and ensure that the patients get timely and efficient care, says Sekander A. Ursani, CPE, MD, medical director.
Ursani makes daily condition rounds with the case managers, social workers, and nursing staff on each unit and attends managed care rounds once a week, during which he meets with all of the case managers and social workers to discuss patients covered by managed care plans.
"Together, we have done good things for the hospital. We’ve reduced length of stay, reduced the denial rate, and improved patient care. I could not do it without the case managers who are my eyes and ears, and it’s not something they could do on their own," Ursani says.
The team on each unit conducts concurrent reviews of cases on a daily basis to make sure the patient meets criteria to remain in the hospital.
"The nurses and case managers are very adept at recognizing when a patient should stay in the hospital or when they’re ready for discharge. They recognize it and tell me," Ursani says.
In addition, Ursani encourages the case managers to call him at any time to discuss a case, even when he’s not on site. For instance, a case manager recently called Ursani with concerns that a patient no longer required a hospital level of care. Ursani reviewed the case with the case manager, spoke with the attending physician, and got him to discharge the patient, preventing an avoidable day.
"The case managers are very skilled. They flag the chart and write notes to the attending physicians, stating their concerns. If the attending physician doesn’t respond, the case managers call me," Ursani says.
The case managers alert Ursani if a case has the potential to be denied, and he appeals the cases concurrently.
"I take the case managers’ notes and supplement them with what I know as a physician, then talk to the medical director of the health plan. We’ve been successful in overturning a significant number of denials through concurrent appeals," Ursani says.
In addition to a medical advisor who works with the entire case management department, Hackensack (NJ) University Medical Center has team physicians who attend daily multidisciplinary rounds on patient care units and act as mentors for the team members, including case managers.
Some of the team physicians are on the medical center staff. Others have individual practices and volunteered to work with the team.
"We start the morning by looking at the patient’s plan of care. Having a rounding physician there allows us to deal with the issues on the spot," says Pat Eason, RN, BSN, administrative director, case management services.
For instance, if a patient’s test results are back, the rounding physician can call the attending physician with the results and get additional treatment started in the morning, rather than after the attending physician comes in the afternoon.
The physician advisor to the entire case management department takes care of questions and concerns that come up after the morning rounds. When he comes in each day, he goes to the case management office and gets a list of the case managers who have requested his assistance and goes to their units.
"We’ve had a physician advisor as long as there has been a case management department. The role has evolved and become a lot stronger in recent years," Eason says.
At Mercy Medical Center, Gormsen meets with the case managers and social workers once a week to discuss whatever issues the staff want to bring up. They go over each individual case, determining how it should be handled and who should handle it. If there is a trend, the team looks further, says Paula Benson, RN, BS, manager of case management.
On occasion, the team invites other hospital staff if there is an issue pertinent to their role. For instance the vice president of managed care is involved when a denial needs to be appealed to a higher level.
When case management staff review cases for appropriate admission or length of stay, they initially intervene with the physician. If they are having difficulty with a physician or a family, they turn the case over to Gormsen.
The case management department has a referral form it faxes to Gormsen’s office. He goes to the floor and talks to the case managers about the case, reviews the chart, and talks with the physician or family.
"It’s a collaborative thing. Clearly, when case managers haven’t had success, I call the physician involved. I don’t always agree with what they’re doing, but it’s still their choice and their patient," he says.
Here are some tips from physician advisors on how to make the role work in your hospital:
- Choose a physician who is interested in taking on the role of physician advisor and wants to make it successful.
"The role does take time. Sometimes it’s a matter of making several phone calls a day, or I might need to make rounds on the floor that day. It depends on what’s going on in the hospital," Gormsen says. - Make sure your hospital’s administration realizes how important a physician advisor is for its success and is willing to compensate him or her for it.
"Once the administration realizes how important a physician advisor is, that’s half the battle," Gormsen adds. - Choose a physician advisor with no conflicts of interest.
"Physician advisors should not be practicing physicians who depend on other attending physicians for referrals," Ursani suggests. - When you refer a case to your physician advisor, be as accurate and complete as possible and include all the information he or she will need to review the case.
"The type of information they include for my review is the key to success, and it’s what separates the good case managers from those who are not so good. If I have specific information, it cuts my time in half," Shah says.
(For more information, contact: Pat Eason, RN, BSN: [email protected]; Marilyn Butler, RN, MS, CCM: [email protected]; Paula Benson, RN, BS: [email protected])
If you arent taking advantage of the assistance your case management physician advisor can offer, or if you dont have an advisor, you may be missing opportunities to move patients safely and efficiently through the continuum of care.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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